The Discharge to Assess model works on the principle of making sure hospital stays are reduced because patients are discharged as soon as acute medical treatment is complete.
The Discharge to Assess model comprises of four pathways, delivered by different services:
Pathway 0 - delivered by Camden social services– The patient does not require any additional support compared to what was in place in their usual place of residence before admission.
Pathway 1 – delivered by Camden Discharge to Assess (this service) - The patient has additional care or reablement needs that can safely be met at home.
Pathway 2 – delivered by CNWL Camden Central Access Team -the patient is unable to return home for a short period of time as they require further rehabilitation or reablement,
Pathway 3 – delivered by Continuing Healthcare -The patient requires intensive time limited support outside of the acute hospital whilst a comprehensive assessment of their complex and ongoing care needs is completed.
In Camden, Discharge to Assess (Pathway 1) is an integrated health and social care community service which provides therapy and/or care for adults in Camden. The team consists of Single Point of Access occupational therapists, physiotherapists, social workers, therapy assistants and support workers. The service offers short-term intensive therapeutic intervention and care for up to five days.
Under Pathway 1 patients are safely discharged home where functional and care assessments can take place. Not only is this setting more appropriate as the environment is familiar to the individual, but it gives us a sense of functional capability. It also prevents decisions about long term care being made in crisis and gives insight into how patients cope and gives the professional an accurate assessment.
Assessments that take place in the home environment include:
- Functional assessments
- Environmental assessments
- Medication review
- Care needs assessment with rapid access to reablement care, if required.
At the end of assessment the team will support the transition to long-term support (if required) as well as develop care plans with patients, and where appropriate their carers, to help alleviate the risk of crisis.
Therapists will also make sure referrals for ongoing therapy input are made prior to discharge from the pathway.
The service is for adults over the age of 18 who live in Camden.
The service is not suitable for people who are medically unstable, have received a new diagnosis of a stroke or where mental health is the main presenting problem.
The identification of patients is done by acute hospitals. A simple referral form is completed and sent to firstname.lastname@example.org. Once accepted we aim to work with referrers to discharge patients from acute hospitals on the same day and assess their needs within two hours of them coming home.
The service is available from 8am to 8pm, seven days a week.
The discharging hospital should make arrangements to transport patient home from hospital.